Eight examples of fraud?

Many dentists and staff have questions regarding bill-ing practices and insurance. While individual insurance carriers may have many requirements for paying claims, these typically are contract rules, referring only to the specific company and contract. A dentist may be in violation of a contract he has entered into with a third-party carrier, such as Delta, without actually committing fraud.

Carol Tekavec, RDH

Many dentists and staff have questions regarding bill-ing practices and insurance. While individual insurance carriers may have many requirements for paying claims, these typically are contract rules, referring only to the specific company and contract. A dentist may be in violation of a contract he has entered into with a third-party carrier, such as Delta, without actually committing fraud.

The following eight situations commonly constitute actual insurance fraud. (You must contact your state insurance commissioner for complete clarification. Fraud situations may vary from state to state.)

1. Billing for services not performed.

This situation seems self-explanatory, but may be more complicated. Obviously, it would be fraudulent to bill for a procedure that you have not performed. What about billing for a crown at the prep date rather than the cementation date? When is the service actually performed? Most dentists send in for payment for crowns at the prep time; but, most insurance carriers consider the crown "complete" only after it is cemented. The patients` benefits manual will indicate contract specifications. (Usually, if a crown is prepped, but never cemented, the dentist is entitled to a partial payment from the insurance carrier. Honest disclosure of the situation normally is all that is required to avoid problems between the carrier and the dentist.)

2. Upcoding

This refers to coding a procedure as having a more extensive degree of difficulty than actually performed. For example: A patient receives a standard prophylaxis (01110), but the insurance carrier is billed for periodontal scaling and root planing (04341).

3. Waiver of co-payments

Patient co-payments are considered to be an essential element to the cost structure of the contract between an insurance carrier and whomever is purchasing the coverage (such as an employer for employees). Waiving co-payments is thought to encourage more usage of the coverage than would normally occur, skewing the original cost structure. In some states, waiving co-payments may be legal under certain conditions. In Colorado, it is not fraud if done for 25percent or less of a dentist`s patients.

4. Waiver of deductibles

As in the case of co-payments, deductibles are considered to be essential to an insurance carrier`s contract cost structure. In some states, waiving deductibles may be legal under certain conditions. In Colorado, it is not fraud if it is done for 25 percent or less of a dentist`s patients.

5. Altering dates of service

The correct date a procedure is performed is important as related to patient eligibility requirements and waiting periods. It is fraudulent to send in a claim for a treatment using a date other than the actual date of service. If a patient asks a dentist to send in a claim using a date other than the actual treatment date and the dentist does so, both the dentist and the patient have committed fraud.

6. Unbundling or improper use of codes

It is considered fraud to use several codes (unbundling) to describe a service on a claim where one code is sufficient. For example: A dentist performs a one-surface occlusal amalgam. He sends in a claim for 09210-Local Anesthesia; 09430-Office Visit; 02140-Amalgam-One Surface; and 03120-Pulp Cap-Indirect, when Code 02140 Amalgam-One Surface is sufficient. (Unbundling is a difficult and controversial concept.)

7. Misrepresenting patient identities

Obviously, performing treatment on one patient and sending in a claim for that person as someone else is fraud.

8. Not disclosing existence of additional or primary coverage

Patients who are covered by more than one dental plan or a medical and dental plan may receive benefits from all plans, provided each plan knows about the others. Sending in multiple claims to different carriers as if they were each the primary carrier is fraudulent.

Contact your state insurance commissioner for complete information on insurance fraud in your state.

Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart, and a national lecturer. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.

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